Priorities in addiction treatment bill debated

Some say inpatient stays are ineffective

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Paul Kusiak of Beverly played with his grandson, Sam, while sitting with his two sons, Jared (left) and Jason.

By Felice J. Freyer
Globe Staff
July 29, 2014

Paul Kusiak calls it “our family’s personal 9/11.” His two sons, four years apart in age, both started struggling with opioid addiction a decade ago. At the same time, Kusiak faced another bruising fight: getting insurance to pay for his sons’ medical care.

He ended up paying out of his own pocket for his sons to participate in 30-day inpatient treatment programs, which he credits with starting them on their recovery. They are both doing well today.

“I’ve had piles of bills, inches and inches tall — denied, denied, denied,” he said. “I should not have to work that hard to get coverage.”

Now Kusiak, a board member of a group that advocates for recovering addicts, is pushing for legislation that would require insurers to cover inpatient addiction treatment for any patient. But insurers and some doctors say the bill, expected to get a vote in the legislative session’s final days this week, promotes a costly and outmoded approach to treatment.

Their objections have stirred an eleventh-hour controversy around a bill promoted as the Legislature’s answer to the state’s opioid crisis, which claimed 668 lives in 2012.

On Friday, 29 insurance and business leaders wrote to Governor Deval Patrick and legislative leaders, saying that certain provisions in the bill would encourage a treatment approach that isn’t based on the latest medical evidence, in an era when medications can enable people to recover from addiction without overnight stays. The critics also complained that the legislation could drive up health care costs — although no one has an estimate on how much the inpatient-care provision would cost.

Notably, the American Society of Addiction Medicine, a professional society of physicians and others who work in addiction treatment, supports the insurers in this argument.

“There’s a widespread misperception that beds are what we need,” said Dr. Amanda Wilson, public policy chairwoman of the society’s Massachusetts chapter. Wilson, who is also president and chief executive of Clean Slate, a company that runs office-based addiction treatment centers, estimates that 95 percent of patients being treated for opioid addiction do not need inpatient care and will do better taking medication and engaging in long-term outpatient treatment, typically lasting 18 to 24 months.

But in the eyes of patient advocates and treatment centers, patients benefit when insurers get out of the way.

That was the message that state Senator Jennifer L. Flanagan heard when she held meetings around the state earlier this year. “People were telling us they were determined to become sober. They would call a hospital or clinic or treatment center and they would be denied” insurance coverage, she said.

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Joanne Anderson, a registered nurse at SSTARaddiction treatment center in Fall River, took a client’s vital signs last week. The center offers both inpatient and outpatient services.

Some families resorted to seeking an involuntary civil commitment as a way to get an addicted relative into inpatient treatment, she said. The number of such cases, in which a judge sentences a person to long-term treatment, increased from 4,107 in 2007 to 4,982 in 2013.

“We’re not encouraging the use of any type of treatment,” Flanagan said. “What we want to see happen is a bill that will allow people to get the treatment they need.”

Legislative leaders are trying to reconcile differing House and Senate versions of the substance abuse bill and a final measure is expected to be released and voted on this week.

The Senate bill requires insurers to pay for up to 21 days of inpatient coverage; this would include both five to seven days of detoxification, the medical care needed when withdrawing from drugs, and inpatient post-detox care, supportive services to help people stay off drugs (commonly known as “rehab”). The House bill requires 10 inpatient days.

Especially worrisome to insurers, both bills limit insurers’ ability to override treating physicians’ decisions. The Senate measure says that any treating physician certified by the Health Policy Commission has the final say, with the patient, on what substance abuse treatment is medically necessary; the House version doesn’t require the doctor to be certified to make such a judgment.

Dr. Stuart Gitlow, president of the American Society of Addiction Medicine, wrote to the Legislature saying that the law “endorses inpatient detoxification as a preferred treatment.”

In an interview, Gitlow acknowledged feeling a little strange about teaming up with insurers. “Ordinarily I’d be fighting on the other side,” he said. “I would normally say, ‘We want parity, we want patients to be able to have access to care.’ ”

But the bill, he said, risks pushing people toward care that is both more intensive and less effective. Today, patients have many options for care other than the traditional rehab stay. Drugs given on an outpatient basis — not just methadone, but also Suboxone and Vivitrol — can help patients through withdrawal and also quiet the cravings over time.

Some people, especially those recovering from alcohol addiction, do need inpatient care, Gitlow said. But the proposed legislation could end up filling the available beds with the wrong patients, he added, and “people who really need treatment might end up on the street.”

Dr. David C. Lewis, founder of the Brown University Center for Alcohol and Addiction Studies, agrees: “Inpatient care should be utilized much less than it has been historically. . . . Arbitrarily saying that inpatient care is available for everybody really isn’t a good idea.”

Told of such comments, Nancy Paull, chief executive of the SSTAR treatment center in Fall River, quickly replied: “Let them live in our shoes with our sick population.”

Paull notes that SSTAR, like most other addiction treatment centers, offers medication-assisted and outpatient treatments as well as the traditional inpatient care. Her treatment center beds are usually full, so she is always looking for alternatives, she said. The treatment providers merely want to be able to work with patients to choose the level of care that best meets their needs, she said. “I’m not saying inpatient is for everybody,” she said. “We have a great understanding of what’s going on and what’s needed, better than someone sitting in an office 1,000 miles away.” Some patients need “clean time” away from the environment where they used; some are young people living with overwhelmed parents, and recovery requires separation, she added.

Gretchen Ertl/Boston Globe

Nancy Paull of SSTAR said of those who question effectiveness of inpatient care: “Let them live in our shoes with our sick population.”

She also noted that inpatient care “is not that expensive” — about $300 a day, much less than a day in an acute-care hospital.

The Institute for Clinical and Economic Review, a Boston-based nonprofit group that studies medical effectiveness, recently conducted a review of methods for treating opioid dependence. Dr. Steven D. Pearson, president and founder, said that studies show long-term medication treatment is more effective for most patients than short-term inpatient detox. When it comes to post-detox treatment, or rehab, Pearson said, the evidence isn’t as strong but it suggests that most patients get “equal if not better results” from long-term outpatient treatment compared with inpatient rehab.

Dr. Richard Saitz of Boston University, chairman of the treatment and services review committee for the National Institute on Alcohol Abuse and Alcoholism, points out that components of effective treatment, such as medication and therapy, can be delivered in either an outpatient or inpatient setting. The decision about which is better depends on nonmedical issues, such as whether the patient has a job, a family, a place to live, and whether he or she is in an environment where others are using drugs.

Saitz agrees with the other addiction specialists who have misgiving about the legislation: “You don’t want to encourage unnecessary inpatient care,” he says.

But addicts, he points out, cost the health care system a lot of money in emergency room visits and other care separate from treating their addiction. And it’s hard to persuade people to enter treatment. So if he had to vote on this bill, Saitz said, “I would vote for less restrictions on clinicians and patients. . . . It’s hard enough to get addiction treatment.”

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